Thank you for having me here.

My name is Jason Pantarotto. I'm the head of radiation oncology at the University of Ottawa and the Ottawa Hospital. I'm here as an expert in the treatment of lung cancer with radiation. Also, I've been involved in the provincial Cancer Care Ontario system, and I can speak to that in a my role as regional lead for radiotherapy for eastern Ontario in the Champlain LHIN, the local health integrated network of 1.3 million people. Further to that, I'm involved in a significant effort at the Ottawa Hospital to address lung cancer wait times. I'll speak to some of the challenges there.

I thought I would reserve my comments for this afternoon to the four components of the resolution passed by the committee.

In terms of the main causes of lung cancer beyond smoking, I think the speakers today have addressed many of those, but I want to make further comments and address as well some of the questions brought up in the last hour.

There are several agents, both man-made and natural, that can cause lung cancer. Many of the industrial agents used in the last 100 years can be inhaled, but frankly, it's difficult to assess the risk of each individual agent. There is clear evidence gathered over the last several decades that agents such as asbestos, diesel fuel, silica dust, and arsenic, whether breathed in or ingested, can cause lung cancer specifically, but there is a latent period of many years between exposure and the actual development of lung cancer.

The findings often show that the insults from these agents work synergistically with the effects of cigarette smoking. Therefore, you see higher rates of lung cancer in smokers rather than non-smokers, given the same exposure. For many industrial exposures, with the effect of cigarette smoking and the fact that it was really so prevalent over the last 60 or 70 years—so many people smoked—it's really quite difficult to tease out the actual impact of many industrial toxins that are out there.

Specific to radon, which of course is not an industrial agent but, as we've heard today, a naturally occurring substance in the earth's crust caused by the natural breakdown of uranium, personally I believe that Health Canada has very good documentation that can be found on their website, but with my patients, and even with my colleagues and my friends and neighbours, radon testing is really not a priority for the general population.

In fact, you can ask yourselves this: how many of you have had your own homes tested for radon? If not, why not? I suspect we have a number of good answers. I think costs are one of the barriers, and if it's a struggle to get people to put four dollars' worth of batteries into a smoke detector, then how do we get people to perform a test, whether it's $99 or $30 or what have you, plus all the things that potentially might need to be done to your home? If there is a synergistic effect between radon and cigarette smoking, then in fact for those populations who smoke more, which typically are those with reduced socio-economic status or less education, their barriers to access or to perform radon testing and then do something about it are arguably even higher.

Moving on to fundraising challenges, there is a general lack of awareness of how prevalent and serious lung cancer is, even amongst health care professionals. With few survivors and hence few advocates to promote research programs, we really haven't been able to get significant fundraising programs to the levels observed for other cancer types. Then again, smoking rates are higher in those segments of the population that I just mentioned, those with a reduced socio-economic status, and historically those groups have not been able to do a good job advocating for themselves, for obvious reasons.

With respect to research related to the causes of lung cancer for men and women, I think there are a number of established causes, cigarette smoking being by far and away number one on that list. I see a lot of research being done on the treatment of lung cancer, which we've heard a little bit about today, and also in terms of prevention and effective screening.

I think screening is key, but it has to be an effective screening program. In Ontario and various other jurisdictions across Canada we have established screens for cancers such as breast cancer, cervical cancer, and colorectal cancer, but if we look at the latest data for Ontario, of eligible women from 2011 to 2013, 62% underwent screening for cervical cancer. For the same period, 59% of eligible women underwent screening, and for colorectal cancer it was much lower, in the range of 30%, despite the fact that colorectal cancer is the number two cancer killer, if you will, in Canada. It's number two of course, with lung cancer being number one. All of that data comes from the Cancer System Quality Index, published by the Cancer Quality Council of Ontario.

To finish off, the emerging best practices for screening was the last item in the resolution. I think we've heard a lot of good information today about how there is some firm evidence behind performing low-dose CT scanning in high-risk populations. I think when you have a screening program, there's a lot of depth there that needs to be addressed. There's accreditation of each facility and the staff that works within them, database management, a recall system for suspicious nodules because you're going to find all sorts of things once you start looking, surveillance clinics, and then of course access to timely lung biopsy. Integration is key.

In Ottawa and the Ottawa area, which has a fairly affluent and well-educated population, according to 2011 data, the time from having an abnormal CT scan to getting treatment for your lung cancer was 117 days for the 90th percentile. That's in Ottawa and that's the story all across the country for various reasons. When you get into some of these other populations, they have a tougher time getting screened once a screening system is set up and a tougher time getting biopsies. That time is even longer.

I just want to finish off in terms of the segments of the population that fall under the jurisdiction of the federal government: aboriginals, the military, incarcerated individuals, and the RCMP. There is evidence in some subgroups of the aboriginal population that smoking rates are high. For the population in Nunavut, and specifically this comes from studies from Professor Kue Young at the University of Alberta, indigenous populations that live around the Arctic Circle in various countries have higher lung cancer rates than do pretty much everyone else in the world. The aboriginal population in Canada specifically seemed to have even higher rates.

Similarly in notable journals like Cancer there is published evidence—though I didn't find any Canadian evidence—that there are higher rates of lung cancer amongst veterans in the American military and Australian military, and that if they get lung cancer, there is a higher likelihood they will die from the disease. I would not be surprised if we saw similar results if studies were performed on the Canadian veteran population, or if they have been performed and I just don't know about them. I would not be surprised if we saw exactly the same thing.

I'll leave it at that, because I believe I'm out of time.

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